Prevention, identification, and treatment of inadequate decompression of the cervical spine.

Inadequate decompression is one of the most common reasons for failed spinal surgery. Understanding the common areas where neural impingement occurs in the cervical spine, recognizing these changes on imaging studies, and recognizing the clinical manifestations help provide an intraoperative template for thorough decompression. A thorough preoperative workup assesses sagittal alignment of the cervical spine, determines if instability exists, identifies the location of the compression, and determines the etiology of the compressive lesion. This information guides the surgeon in deciding whether an anterior, a posterior, or a combined anterior and posterior approach will provide the most adequate decompression. It also will help determine whether arthrodesis is needed to provide optimal neurologic recovery. Patients who have had surgery and present with persistent neurologic symptoms, or who do not recover as expected, pose a unique challenge. The surgeon must determine if persistent compression exists, look for evidence of instability, and evaluate for irreversible spinal cord changes. Alternatively, other causes of neurologic changes, unrelated to neurologic impingement, must be ruled out. The initial step in achieving the goal of complete neurologic decompression is a thorough preoperative evaluation for static and dynamic causes of compression. The most important concept regarding inadequate decompression is to avoid it with careful preoperative planning of the index procedure.